The quality implications of very short homecare visits and the terms and conditions of the homecare workforce have received significant attention over the last year. It is vital that people who use homecare services have sufficient time allocated to meet their needs effectively and with dignity, and receive services from workers who are highly-motivated and willing to make community-based care a long-term career choice because they are properly rewarded for the essential services they deliver.
Recent public scrutiny has damaged confidence in social care, but short visits and the use of zero hours contracts are inescapably linked. In some quarters, there are still suspicions that outsourcing the delivery of social care to the private sector has led to a lowering of quality and deterioration in workforce conditions as a result of a profit motive. However, the root cause is really the way that homecare services are commissioned by councils (and to a lesser extent by the NHS).
Around 70 per cent of homecare in England is purchased directly or indirectly by the State, and it is largely councils using their dominant purchasing power to drive down prices and ration the amount of service people receive to contain costs, which have created the issues the sector faces.
Attention on short visits
A series of investigations and reports have focused attention on short homecare visits. The Equality and Human Rights Commission’s (EHRC) report, Close to Home: An inquiry into older people and human rights in home care, commented on the experience of people receiving homecare and there has been significant reporting by current affairs programmes on the use of short homecare visits. While the focus has been on 15-minute visits, which account for around 10 to 16 per cent of care commissioned by councils, the wider picture is even more worrying. In 2012, the United Kingdom Homecare Association (UKHCA) estimated that 73 per cent of homecare visits in England were for no more than 30 minutes. As the majority of people receiving state-funded homecare in England and Wales will have a significant degree of frailty or disability, this suggests that much of the personal care delivered in people’s own homes is likely to be shoe-horned into inadequate time-slots. This is incompatible with the responsive, dignified care that people who use services expect, and hugely stressful for frontline care workers.
Despite much positive discussion around commissioning homecare services to achieve the desired outcomes for people who use such services, the reality is that councils continue to stipulate the amount of time allocated for specific care tasks to be undertaken, and pay providers solely for ‘contact time’ (time spent in the service user’s home). This type of prescriptive commissioning may feel like an effective way of rationing severely limited resources, but it creates an inflexible system where neither the provider, nor the care worker, is likely to be paid for any extra time the service user may require for fluctuating needs or emergencies, particularly where the process to reclaim payment for additional time spent can be so onerous as to be unviable.
Individual Service Funds (ISFs) offer a greater degree of flexibility by allowing the person using the service to agree how their needs are met directly with their care provider, who manages an allocated personal budget on their behalf. While ISFs do not necessarily increase the total amount of time available, and aren’t suitable for everyone, they can provide a better way of getting the most out of a finite resource. The service user and provider can work out the best combination of visits (or other services) according to the user’s preferences, without needing repeated referrals back to the commissioner to change care plans or visit lengths.
However, until we can move away from the commoditisation of homecare as a service paid for in minutes or fractions of an hour, commissioning for outcomes will be largely a matter of rhetoric. A system of payment-by-results would appear to be the answer, but such systems are in their infancy in social care. For a system to be effective, it must be designed and tested with independent sector providers before being implemented. A badly designed system, particularly if imposed top-down by commissioners with insufficient commercial experience, could be disastrous for the stability of local providers.
A minimum price for homecare
Commissioning very short homecare visits while paying for ‘contact time’ creates an additional problem for providers and their ability to comply with the National Minimum Wage Regulations. Minutes shaved-off a homecare visit save councils money, but increase providers’ costs disproportionately, as a worker’s travel becomes a larger proportion of the hourly cost.
UKHCA recently produced a minimum price for homecare services of £15.19 per hour, necessary to meet legal compliance with the National Minimum Wage and maintain a sustainable homecare service. Using the Freedom of Information Act, BBC Radio 4’s File on 4 – Cut-Price Care was able to establish that only four out of 101 councils paid at least this rate for the homecare services they commissioned.
UKHCA’s minimum price was not an exercise in wishful-thinking. UKHCA has published the assumptions used in its calculations, including payment of flat-rate National Minimum Wage for both the time workers deliver care and time spent travelling, an issue recently scrutinised by HM Revenue and Customs in its report National Minimum Wage: Compliance in the social care sector.
UKHCA’s minimum price presents an uncomfortable challenge to local councils paying an average below £15.19/hour. They must either demonstrate why UKHCA’s assumptions are unrealistic; or admit that they are forcing providers into the dangerous territory of non-compliance with the law and unsustainable staff turnover rates; or that they are tacitly asking providers to cut corners in areas which directly affect the quality of services, such as training, supervising or managing a mobile workforce.
A second EHRC report, Close to Home Recommendations Review, commented on the added implications of under-funded care, ‘Squeezing hourly rates, or placing too much emphasis on cost rather than quality, may increase the risk of rushed visits. It may also lead to ‘call cramming’, whereby providers over-book visits on a care worker’s rota, making it impossible for them to spend the allocated time on each visit.’ The Commission makes the link between such inflexibility and a risk to the human rights of people who receive homecare.
While it is an extremely unpopular message for politicians or local authority commissioners, the underfunding of social care is a genuine issue that will not be solved by slicing the cake more thinly, or looking for ‘efficiencies’ in a system which is already exhausted.
Zero hours in homecare
The rise in the use of zero hours contracts across business sectors has been analysed by the Institute of Personnel Management, and their use in social care has been criticised by the Cavendish Review for Government and the Kingsmill Review for the Opposition.
Feedback from homecare providers suggests that many of the drawbacks reported in mainstream media, including ‘working one day and not the next’, or being prevented from working for other employers, are rare in the homecare sector. We also hear from providers who operate both guaranteed-hours and zero-hours contracts, that even when given a choice, many workers continue to opt for more flexible working arrangements.
Risks to the continuity of care for people who use services and the unpredictability of income for workers are, however, important factors to consider. The use of zero-hours contracts has been extensive in the homecare sector for well over a decade. UKHCA believes that, unlike other sectors, their use has not increased significantly as a result of public spending constraints. However, the economic environment makes their use a certainty for the foreseeable future. The palatability of zero-hours contracts for the workforce and observers has no doubt been worsened by employers struggling to keep workers’ pay rates above annual increases in National Minimum Wage.
Service users’ needs have always changed from week to week and require a degree of flexibility which has meant that zero-hours contracts have been extremely useful in responding to changing demand. However, more recently, as councils have pursued the noble aim of personalisation and choice of provider (or the more stark reality of placing new packages of care at the lowest price available), many providers face increasingly unpredictable patterns of purchase.
A reduction in the use of zero hours contracts is more likely to be successful where councils can guarantee volume purchase, which either necessitates a return to block contracting arrangements, or a radical reduction in the number of ‘approved providers’ that councils trade with.
However, the aggressive price-cutting by councils, paying £2 or £3 per hour below the real price of care, simply does not leave money to pay for care workers’ downtime. Even where employers will be able to offer some degree of guaranteed working, such contracts are likely to be restricted to peak-times of activity, such as early morning and late evenings, where there are particularly concentrated periods of activity.
Calls for the sector to abandon zero hours contracts, without a complete reassessment of how much such services will cost the State, are naïve in the extreme. If central Government and local councils are serious in a desire to see providers offer guaranteed hours contracts, they must back their commitment with sufficient funding and adequate commissioning of state-funded care, otherwise they are making empty promises to the workforce and people who use services.
Without considered action on the funding, pricing and contracting of homecare services, the social care sector faces a perfect storm.
Colin Angel is Policy and Campaigns Director at United Kingdom Homecare Association.